KASUS TUTORIAL

BLOK RPS

REPRODUCTIVE SYSTEM TUTORIAL

MATERIALS FOR TUTORS

CONFIDENTIAL

MODULE 1 : GENERAL REPRODUCTIVE SYSTEM

SUB MODULE 2 : MALE REPRODUCTIVE SYSTEM

TUTORIAL TOPIC : PUBERTY

TUTORIAL CASE : SAM AND FRIENDS

MEDICAL EDUCATION UNIT (MEU)

FAKULTAS KEDOKTERAN
UNIVERSITAS PEMBANGUNAN NASIONAL “VETERAN” JAKARTA
2020
KASUS TUTORIAL
BLOK RPS

BLOCK : REPRODUCTIVE SYSTEM

TOPIC :

 Physiology of puberty

Related topic :
 Physiology of male reproductive system

Theme :

The purpose of this week is to describe the anatomy, histology, physiology, of the male
and to review female reproductive system, hypothalamic – pituitary – gonadal axis, end
organ response, as well as pathology anatomy, clinical pathology, pharmacology,
pathophysiology, also to recognize the puberty process in male and female

Objectives :

At the end of the week, the students will be able to:

1. Describe the anatomy, and histology of human reproductive higher centers such as
hypothalamus and pituitary, the male reproductive organs (Dept. of Anatomy and
Histology).
2. Explain the definition and physiology of spermatogenesis, interaction of related
hormones from hypothalamus, pituitary and testes (the H-P-O axis) (Dept. of
Physiology).
3. Explain the definition and physiology of puberty, interaction of related hormones
from hypothalamus, pituitary and testes (the H-P-O axis) and its impact on the
reproductive system development (Dept. of Physiology).
4. Explain the role of sex steroid hormone in growth and development process (Dept.
of Pharmacology & Physiology).
5. Explain the definition and etiology of pubertal disorders.
6. Explain basic physical examination in sexual maturity (Dept. of Pediatrics).

Page 1

You are a medical student assigned to assist a pediatrician during her visit to a junior high
school in east Jakarta, as a spoke-person in a talk show held in main hall of the school.
The topic of the talk show is about puberty and the audiences are the 6th to 8th graders.
In the middle of the presentation by the pediatrician, a student raises his hand asking
permission to ask a question. This student is Sam, a boy age 12 year old, asks why his
sister age 10 year old has almost the height as he is right now. Sam’s height is 138 cm
and his weight is 30 kg while his sister is 134 cm height and 30 kg in weight.
Another student raises her hand desire to ask too, she is Puti age 13 year old. Puti asks
about her ‘changing’ body that made her male friends sometime teased her. She noticed
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UNIVERSITAS PEMBANGUNAN NASIONAL “VETERAN” JAKARTA
2020
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that her breasts are ‘growing’ and hair is growing in ‘some area’ she embarrassed to
mention. Her question makes lots of students whispering that they have the same
‘situation’ going on themselves.

1. What would you explain to Sam? Do you think it is normal?

2. What would be the factors that influence growth and development in boys?
3. What would you think by the ‘changing’ body meant by Puti?
4. How is that happened?
5. How do you measure sexual maturity in male and female?

Tutor’s guiding questions :

1. Can you explain anatomy, physiology, and histology of male reproductive system?
2. How do you explain growth and development of male reproductive system?
3. Can you review anatomy, physiology, and histology of female reproductive system?
4. How do you explain growth and development of female reproductive system?

Page 2

The discussion continues with another female and male students raise their hands
anxiously to ask another question. The male student name Andry age 14 year old proceed
a question what changes will happen to his body at his age because he begins to have
‘wet dream’ and how this could happen to a boy at his age.
Before you can answer Andry’s question, a female student, Tyka age 14 year old, tells
that she had her first period last week. She wonders how a female at her age having this
kind of process.
Rara, a female student age 11 year old asks if there could be disorders affect their growth
and development.

1. What would you explain to Andry?

2. What would you explain to Tyka?
3. What would you explain to Rara?

Tutor’s guidingf questions :

1. What is the definition of puberty?

2. How do you explain puberty in male and female? What are the factors affect male
and female puberty?
3. How do sex hormone play role in male and female puberty?
4. Are there any other hormones involved with male and female puberty process?
5. How does puberty in male and female differ? Why?
6. What does ‘wet dream’ mean?
7. Could you explain cellular process of gametogenesis in male and female?
MEDICAL EDUCATION UNIT (MEU)
FAKULTAS KEDOKTERAN
UNIVERSITAS PEMBANGUNAN NASIONAL “VETERAN” JAKARTA
2020
KASUS TUTORIAL
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Page 3

Epilogue

The discussion is going to be more interesting as the students are anxious to find out why
they are changing differently between male and female students. You keep answering
those questions until finally time is up and the talk show has to end.
Some of the students still eager to get explanation on other questions but they are
embarrassed to pop the question in front of their friends. They are asked to contact you
through email to get answer. They agree to that offer and ask your email address.

TUTOR’S MANUAL
Learning objectives to discuss are :

1. The male reproductive system

The male perineum, including the mons pubis, urethra, scrotum and penis
A. The anatomy of the penis :
* Root : crura & bulb
* Body : corpora cavernosa & corpus spongiosum.
* Glans, prepuce  frenulum.
* Structure, erection
* Arteries, veins, nerves & lymphatics.
The testis and accessory duct, i.e.
*epididymis, ductus deferens, urethra including arterial supply, venous and
lymphatic drainage, innervations

B. The anatomy of the accessory gland, i.e. seminal vesicles and ducts, prostate glands,
bulb urethral glands
* Prostate gland:
* Position & parts
* Lobes
* Fascial sheath Retrovesical septum, attachments
* Structure, ducts & openings on prostatic urethra
* Veins, arteries, lymphatics & nerves

TLWBA to recognize anatomical functional relationship of the hypothalamus,

neurovascular, and target cells of the pituitary

TLWBA to recognize the regulatory role of secretory activities of the pituitary hormones,
including long and short-term biorhythmicity, their target organ and the feedback systems
MEDICAL EDUCATION UNIT (MEU)
FAKULTAS KEDOKTERAN
UNIVERSITAS PEMBANGUNAN NASIONAL “VETERAN” JAKARTA
2020
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TLWBA to discuss the distribution and cellular characteristics of pituitary- hormone

producing cells with special reference to gonadotrope, somatotrope and lactotrope

TLWBA to discuss the structure and function of pituitary reproductive hormones and
neuropeptides (GnRH, TRH, somatostatin, etc)

TLWBA to recognize neuroendocrine regulation of the puberty

2. The female reproductive system

Describe the anatomy, histology and physiology of :

1. Boundaries and triangle of the perineum, perineal fascia and perineal pouch,
pelvic diaphragma including the ischio-anal fossa, pudendal canal, anal canal (i.e,
sphincters, inferior structures, arterial supply, venous and lymphatic drainage,
innervation.
2. The urogenital diaphragm
3. The vulva , including the mons pubis, labia majora, labia minora, clitoris,
vestibule of the vagina, bulbs of vestibules, the greater vestibular glands arterial
supply, venous drainage, lymphatic drainage and innervation.
4. The anatomy of the ovaries, including the ligaments, arterial supply, venous
drainage, lymphatic drainage and innervation.
5. The anatomy of the uterine tube, including the division, relationship, arterial
supply, venous drainage, lymphatic drainage and innervation
6. The anatomy of the uterus, including the ligaments division, relationship, arterial
supply, venous drainage, lymphatic drainage and innervations
7. The anatomy of the vagina, including the relationship, arterial supply, venous
drainage, lymphatic drainage and innervations
8. Describe anatomy of the breast, describe breast quadrants, explain arterial supply
and venous drainage of the breast, explain nerve supply of the breast, explain
lymphatic drainage

MEDICAL EDUCATION UNIT (MEU)

FAKULTAS KEDOKTERAN
UNIVERSITAS PEMBANGUNAN NASIONAL “VETERAN” JAKARTA
2020
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ATTACHMENT
Growth and Development : Tanner Score Primary and Secondary Sexual
Characteristics in adolescent

Growth and development is important for pediatric and health professional, and its
subject is covered both in pediatric and biology anthropology. In biological anthropology,
the study of growth is called auxology. The history of the study of growth and
development is a long process that began with the description of human observation of
their posture, skills, behavior, size, shape and structure. Following the descriptive period
as pictorial representation, then growth seriation, growth quantification,
iconometrography, and individual growth, these six periods of growth study were
mentioned by Boyd.
Growth often refers in changes in size of body parts or whole body, while development
often refers to function, including social, cognitive, structural, and emotional changes
related to environment.
Growth and development is important to be understood by medical students because in
medical profession, physicians ought to understand normal human growth and
development. By understanding the normal growth, any disturbance of growth can be
detected early to further be treated or managed. Various factors could disturb the normal
growth and development, including genetic defect, malnutrition, and disease, among
growth and development can be measured not only by measurements, but also by
observation. The physical growth and development include dental, skeletal, sexual
maturity, height, and weight. This practical guidance focuses in Tanner’s Score System to
understand physical growth and development in adolescent males and females.
Adolescent is often categorized into early, middle, and late, which correspond to their
stages of pubertal development. This is unique in individuals regardless of their
chronological age.
Early adolescent refers to sex maturity ratings (SMR, Tanner stage) score 2, which is the
first stage of puberty. SMR 1 refers to pre-adolescent.

Sex Maturity Stages in Girls

SMR
Pubic Hair Breast
stage
1 Preadolescent Preadolescent
2 Sparse, lightly pigmented, straight, Breast and papilla elevated as small
medial border of labia mound, areolar diameter increased
3 Darker, beginning to curl, increased Breast and areolar enlarged, no contour
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amount
4 Coarse, curly, abundant but amount
less than in adult
5 Adult feminine triangle, spread to
medial surface of thighs
separation
Areola and papilla form secondary
mound
Mature, nipple projects, areola part of
general breast contour

Sex Maturity in Boys

SMR
Pubic Hair Penis Testes
stage
1 None Preadolescent Preadolescent
2 Scanty, long, slightly Slight enlargement Enlarged scrotum, pink
pigmented textures altered
3 Darker, start to curl, Longer Larger
small amount
4 Resembles adult type, Larger, glans and breadth Larger, scrotum dark
but less in quantity, increase in size
coarse, curly
5 Adult distribution, Adult size Adult size
spread to medial
surface of thighs

Central Issues in Early, Middle, and Late Adolescent

Variable Early Adolescent Middle Adolescent Late Adolescent

Age (year) 10 - 13 14 - 16 17 – 20 and
beyond
Sexual Maturity 1 - 2 3 -5 5
Rate
Somatic Secondary Height growth Slower growth
characteristic: peaks, body shape
Beginning of rapid and composition
growth, awkward change, acne and
odor, menarche,
spermache
Sexual Sexual interest Sexual drive surges, Consolidation of
usually exceeds experimentation, sexual identity
sexual activity question of sexual
orientation
Cognitive and Concrete operations, Emergence of Idealism,
moral conventional abstract thought, absolutism
morality questioning mores,
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self-centered
Self concept Preoccupation with Concern with Relatively stable
changing body, self attractiveness, body image
conscious increasing
introspection
Family Buds for Continued struggle Practical
independence, for acceptance of independence,
ambivalence greater autonomy family remains
secure base
Peers Same-sex groups, Dating: peer group Intimacy: possibly
conformity, cliques less important commitment
Relationship to Middle school Gauging skills and Career decisions
society adjustment opportunity (e.g. dropout,
college, work)

Puberty

The transition from a non reproductive to a reproductive state during puberty requires
maturation of the entire hypothalamic-pituitary-gonadal axis. Before the child reaches
age 10 years, plasma LH and FSH levels are low despite low concentration of gonadal
hormones and inhibin. Blockade of normally inhibitory opioid receptors does not increase
plasma LH and FSH. Therefore either the negative feedback system is inoperative or the
hypothalamus and pituitary gland are exquisitely sensitive to testosterone, estradiol, and
inhibin. One factor in puberty may thus be the gradual maturing hypothalamic neurons
that lead to an increased synthesis and release of GnRH. The time and rate of onset of this
maturational process may well be genetically pre programmed because familial patterns
are apparent. Other central nervous system components may influence this process.
Nocturnal secretion of melatonin from the pineal gland declines from childhood to adult
life, and destruction of the gland may cause premature puberty. However, it has not been
established that in humans, melatonin is a normal suppressor of gonadotrophins during
childhood or the rate of decline of melatonin is a normal regulator of the onset of puberty.

As puberty approaches, a pulsatile pattern of LH and FSH secretion appears. The ratio of
plasma LH to FSH rises as the pulse frequency increases. Furthermore, during early and
middle puberty, but at no other time of life, a nocturnal peak in LH secretion is observed.
This then disappears as adult status is reached. The gonad itself is not necessary for these
changes in GnRH and gonadotropins to occur.

During early puberty the responsiveness of the pituitary gland to GnRH changes so that
LH exceeds FSH output. This may result from increased synthesis and storage of LH in
response to pulsatile GnRH secretion because the later allows better maintenance of
GnRH receptors. Although the gonadal target cells respond to LH in childhood, their
responsiveness is augmented during puberty. Therefore testosterone levels in males and
estradiol levels in females increase sharply. In addition, FSH stimulates a pubertal rise of

MEDICAL EDUCATION UNIT (MEU)

FAKULTAS KEDOKTERAN
UNIVERSITAS PEMBANGUNAN NASIONAL “VETERAN” JAKARTA
2020
KASUS TUTORIAL
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inhibin levels in both genes. Thus this period can be viewed as a cascade of increasing
maturation from hypothalamic to pituitary to the gonadal level. Once the adult pattern of
gonadotropin secretion is established, the basal plasma concentrations of LH and FSH
(approximately 10-11 molar) are similar in men and women. An important distinguishing
feature between the genders is the additional establishment of a dramatic monthly
gonadotropin cycle in females only, with the LH burst greatly exceeding the FSH bursts.

Male Puberty

Beginning at an average age of 10 to 11 and ending at average age of 15 to 17, males

develop full reproductive function, Leydig cell proliferation, and adult levels of
androgenic hormones. Secondary to activation of the testis, males acquire adult size and
function of the accessory organs of reproduction, complete secondary sexual
characteristics, and adult musculature. They undergo a linear growth spurt and the
epiphyses close when they attain adult height. It must be stressed that this process can
start as early as age 8 and as late as 20, without any evidence of disease. The mechanisms
of pubertal onset were described previously.
Enlargement of the testis is the first and most important clinical sign of puberty. This
represents principally an increase in the volume of seminiferous tubules, and it is
preceded by small increases in plasma FSH. Leydig cells appear, and testosterone
secretion is stimulated, as plasma LH increases. Plasma testosterone then climbs rapidly
over a 2-year period, during which time pubic hair appears, the penis enlarges, and the
peak velocity in linear growth is achieved. Sometimes during this interval – at a median
age of 13 years – sperm production begins. In about one third of boys, breast growth and
tenderness appear transiently. This probably reflects increased production of estradiol
secondary to LH stimulation. As testosterone levels continue to climb, the breast tissue
regresses. One to two years after adult testosterone levels are reached, closure of the
epiphyseal growth centers ands puberty.

Female Puberty

The general process of initiation of puberty has already been described. Reproductive
function begins after an increase in gonadotropin secretion from the low levels of
childhood. Female differs from male in more clearly demonstrating an earlier rise in FSH
than in LH. Budding of the breasts is the first observable physical sign of puberty and
coincides with the first detectable increase in plasma estradiol, as ovarian secretion
commences. The onset of menses (menarche) occurs approximately 2 years later, after
LH levels have risen more sharply. Menarche is correlated with both body and bone
maturation. It can be delayed by under nutrition or strenuous exercise and occurs later in
large sibships. Menarche is accelerated by obesity and blindness.
Because development of the positive feedback effect of estradiol necessary to provoke a
preovulatory LH burst is the last step in maturation of the hypothalamic pituitary ovarian
unit, ovulation usually does not occur in the first few cycles. Initial irregularity of
menstrual cycles is therefore common, as the menstrual bleeding is induced by
withdrawal of estrogen from graafian follicles undergoing atresia.
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The growth spurt and the peak velocity of growth are characteristically earlier in girls
than in boys. Further increase in height usually ceases 1 to 2 years after the onset os
menses. The development of pubic hair precedes menses, and it correlates best rising
levels of adrenal androgens, especially DHEA-S.
The Testes

Anatomy

The human testes are normally situated in the scrotum, where they are maintained at a
temperature 1 to 2˚C below that of the body temperature. This lower temperature is
essential to normal sperm production and is partly maintained by intertwined coiling of
arteries and veins to facilitate heat exchange between them. Each testis weighs about 40 g
and has a long diameter of 4.5 cm. The testes receive blood from spermatic arteries,
which arise directly from the aorta. The right spermatic vein drains into the inferior vena
cava, whereas the left drains into ipsilateral renal vein. Eighty percent of the adult testis is
made up of the seminiferous tubules; the remaining 20% is composed of supportive
connective tissue, throughout which the Leydig cells are scattered. The seminiferous
tubules are a coiled mass of loops; each loop begins and ends in as ingle duct, the tubulus
rectus. The tubuli recti, in turn, anastomose in the testis and eventually drain via the
ductuli efferentes into the epididymis. The later constitutes a storage and maturation
depot for spermatozoa. From the epididymis the spermatozoa are carried via the vas
deferens and ejaculatory duct into the penis, to be emitted during copulation.

The structure of the adult seminiferous tubule is complex. Each seminiferous tubule is
bounded by a basement membrane, separating it from th Leydig cells, the peritubular
(myoid) cells, and the surrounding connective tissue. Immediately beneath the basement
membrane are spermatogonia (germ cells) and Sertoli cells. As the spermatogonia divide
and develop successively into spermatocytes and spermatids, a column of cells is formed
that reaches from the basement membrane to the lumen of the tubule and culminates in
the spermatozoa. In contrast, the cytoplasm of each Sertoli cell extends all the way from
basement membrane to the lumen. This cytoplasm invests the spermatogonia and its germ
cell line successors.

Special processes of the Sertoli cell cytoplasm fuse into tight junctions, which create two
compartments of intercellular space between the basement membrane and the lumen of
the tubule. The spermatogonia and early primary spermatocytes lie within the proximal
basal compartment, whereas the later spermatocytes and subsequent stages in
spermatozoon development lie in the distal adluminal compartment. This separation
continues a barrier to the blood, which is partly established by overlapping peritubular
cells and by the basement membrane. In even more discriminating fashion, the cytoplasm
of the adjacent Sertoli cells excludes a variety of circulating substances from the
intercellular fluid that bathes the maturing germ cells and also from the seminiferous
tubular fluid in which the spermatozoa will begin their outward journey. Another
consequence of this barrier is to prevent late spermatogenic product from reaching the
blood stream, where, if recognized as foreign, they could evoke rejection mechanisms.
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In short, the testis consists of separate bit interacting functional elements. The first
element is the Leydig cells, which are pure steroid-secreting cells whose major product,
testosterone, has both vital local effects on germ cell replication and actions on distant
target cells. The second element consists of peritubular myoid cells, which secrete local
regulatory products and may produce physical effects on the tubules and the vasculature.
The third element is the seminiferous tubules, which carry out the process of
spermatogenesis while bathed in locally generated testosterone and Sertoli cell products.

References :

1. Nieschlag E, Behre HM. 2000. Andrology Male Reproductive Health and

Dysfunction 2nd ed. Springer. Münster
2. WHO. 2000. WHO Laboratory Manual for The Examination of Human Semen and
Sperm-Cervical Mucus Interaction 4th ed. Cambridge University Press. New York
3. Anderson JE. 1983. Grant’s Atlas of Anatomy 8 th ed. Williams & Wilkins.
Baltimore
4. Moore KL, Dalley AF. 1992. Clinically Oriented Anatomy 4 th ed. Lippincott
Williams &Wilkins. Baltimore
5. Spalteholz W, Spanner R. 1987. Atlas Anatomy Manusia edisi 16. EGC Penerbit
Buku Kedokteran. Jakarta
6. Berek JS, Adashi EY, Hillard PA. 1996. Novak’s Gynecology 12 th ed. Williams &
Wilkins. Baltimore
7. Sperrof L, Glass RH, Kase NG. 1999. Clinical Gynecologic Endocrinology and
Infertility 6th ed. Lippincott Williams & Wilkins. Baltimore
8. Robaire B. 1995. Handbook of Andrology 1st ed. The American Society of
Andrology. USA
9. Martini FH. 2006. Fundamentals of Anatomy and Physiology 7 th ed. Pearson-
Benjamine Cumings. San Fransisco.
10. Other references beyond above is recommended.

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FAKULTAS KEDOKTERAN
UNIVERSITAS PEMBANGUNAN NASIONAL “VETERAN” JAKARTA
2020
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Adolescence and Maturity

Adolescence begins at puberty, the period of sexual maturation, and ends when the
growth is completed. Three major hormonal events interact at the onset of puberty.
1. The hypothalamus increases its production of gonadotropin releasing hormones
(GnRH). Evidence indicates that this increase is dependent on adequate level of
leptin, a hormone released by adipose tissues.
2. Endocrine cells in the anterior lobe of pituitary gland become more sensitive to
the presence of GnRH, circulating levels of FSH and LH rise rapidly.
3. Ovarian or testicular cells become more sensitive to FSH and LH initiating (1)
gamete production, (2) the secretion of sex hormones that stimulates the
appearance of secondary sex characteristics and behaviors, and (3) a sudden
acceleration in the growth rate, culminating in closure of the epiphyseal
cartilages.
The age at which puberty begins varies. Puberty generally starts at about age 10 – 15 in
boys, and 9 – 14 in girls. Many body systems alter their activities in response to
circulating sex hormones and to the presence of growth hormone, thyroid hormone, PRL,
and adrenocortical hormones, so sex-specific differences in structure and function
develop. At puberty endocrine system changes induce characteristic changes in various
body systems.

Integumentary System. Testosterone stimulates the development of terminal hairs, on

the face and chest, whereas under estrogen stimulation those follicles continue to produce
fine hairs. The hair line recedes under testosterone stimulation. Both testosterone and
estrogen stimulate terminal hair growth in the axillae and genital area. Androgens, which
are present in both sexes, also stimulate sebaceous gland secretion and may cause acne.
Adipose tissues respond differently to testosterone than to estrogens, and this difference
produces changes in distribution of subcutaneous body fat. In women, the combination of
estrogens, PRL, growth hormone, and thyroid hormones promotes the initial development
of the mammary glands. Although the duct system becomes more elaborate, true
secretary alveoli do not develop, and much of the growth of the breasts during this period
reflects increased deposition of fat rather than glandular tissue.

Skeletal System. Both testosterone and estrogen accelerate bone deposition and skeletal
growth. In the process, they promote closure of the epiphysis and thus place a limit on
growth in height. Estrogens cause more rapid epiphyseal closure than thus testosterone.
In addition, the period of skeletal growth is shorter in girls than in boys, and girls
generally do not grow as tall as boys. Girls grow most rapidly between ages 10 and 13,
whereas boys grow most rapidly between ages 12 and 15.

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Muscular System. Sex hormones stimulate the growth of skeletal muscle fibers,
increasing strength and endurance. The effects of testosterone greatly exceed those of the
estrogens, and the increase of muscle mass accounts for significant sex differences in
body mass, even for males and females of the same height. The stimulatory effects of
testosterone on muscle mass have produced an interest on anabolic steroids among
competitive athletes of both sexes.

Nervous System. Sex hormones affect central nervous system centers concern with
sexual drive and sexual behaviors. These centers differentiated in sex-specific ways
during the second and third trimesters, when the fetal gonads secrete either testosterone
(in males) or estrogens (in females). The surge in sex hormone secretion at puberty
activates the CNS centers.

Cardiovascular System. Testosterone stimulates erithropoiesis, thereby increasing the

blood volume and the hematocrit. In female whose uterine cycles have begun, the iron
loss associated with menses increases the risk of developing iron-deficiency anemia. Late
in each uterine cycle, estrogens and progesterone promote the movement of water from
plasma into interstitial fluid, leading in an increase of tissue water content. Estrogens
decrease plasma cholesterol levels and slow the formation of plaque. As result,
premenopausal women have a lower risk of atherosclerosis than do adult men.

Respiratory System. Testosterone stimulates disproportionate growth of the larynx and a

thickening and lengthening of the vocal cords. These changes cause a gradual deepening
of the voice of males compared with that of females.

Reproductive System. In males, testosterone stimulates the functional development of

the accessory reproductive glands, such as prostate gland and seminal vesicles, and helps
promote spermatogenesis. In females, estrogen targets the uterus, promoting a thickening
of the myometrium, increasing blood flow to endometrium, and stimulating cervical
mucus production. Estrogens also promote the functional development of accessory
reproductive organs in females. The first few uterine cycles may or may not be
accompanied by ovulation. After the initial stage, the woman will be fertile, even though
growth and physical maturation will continue for several years.

After puberty, the continue background secretion of estrogens or androgens maintains the
foregoing sex-specific differences. In both sexes, growth continues at a slower pace until
age 18 – 21, by which time most of epiphyseal cartilages have closed. The boundary
between adolescence and maturity is hazy, because it has physical, emotional, and
behavioral components. Adolescence is often said to be over when growth stops, in the
late teens or early twenties. The individual is then considered physically mature.

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